In 2007, Salam Fayyad accepted the dual post of finance minister and prime minister in the Palestinian Authority (PA). The financial management practices he implemented during his first period as finance minister, from 2002 to 2004, had deteriorated. During the preceding two years, from November 2005 to March 2007, the government had resumed dealing largely in cash, had kept poor records of government financial transactions, and had added more employees to an already bloated public payroll. To reinstitute good practices and implement new reforms, Fayyad and his finance ministry colleagues also had to overcome challenges related to the division of the Palestinian territories into two separate areas governed by competing political parties. Fayyad relied heavily on a small group of trusted staff, delegated important responsibilities so he could also take on the demanding job of prime minister, and set clear guidelines to maximize the long-term benefits from any external technical assistance the ministry hired.  Under his guidance, the ministry rehabilitated financial records and quickly created a new financial information system by adapting existing, locally built software; reformed the way the PA used commercial bank accounts to conduct its financial transactions; and filled gaps in capacity.  

Tristan Dreisbach and staff drafted this case study based on multiple conversations with Salam Fayyad in Princeton, New Jersey, during 2019, as well as other interviews conducted in Ramallah, Nablus, Jericho, and Washington, D.C. the same year.  The case is part of a series on state building in Palestine in 2002–05 and 2007–11. Case published June 2022.

When Salam Fayyad became finance minister of the Palestinian Authority in June 2002, the interim government was starved for cash and faced strong internal and external pressure for reform. To ensure the government could manage revenues and expenditures with fidelity, Fayyad had to improve the functioning and the professionalism of the ministry. He moved quickly to revise core procedures and change the organization’s culture. As he did so, he also began to transform the ministry from an organization based on personal allegiances into one based on institutional policies and standards. Success in that arena during the next three years depended on building coalitions to maintain support for reform as well as marshaling capacity within the ministry itself—by reshaping expectations, centralizing control, unifying geographically divided operations, and fostering talent.

Jennifer Widner and Tristan Dreisbach drafted this case study based on multiple conversations with Salam Fayyad in Princeton, New Jersey, during 2019, as well as other interviews conducted in the Palestinian cities of Ramallah, Nablus, and Jericho in June and July of the same year. The case is part of a series on state building in Palestine, 2002–05 and 2007–11. Case published March 2022.

When Salam Fayyad became finance minister of the Palestinian Authority (PA) in June 2002, the government was struggling to manage expenditures effectively and to deliver the budget to the legislative council on time. Success in addressing those problems required winning acceptance from President Yasser Arafat and other top officials for new work processes, securing other ministries’ compliance with changes in operations, and instituting radical new levels of transparency. Fayyad focused on fixing the system instead of investigating past malfeasance. Under his watch, the finance ministry began engaging with the council’s budget and finance committee, instituting monthly financial reporting, introducing reliable internal control and audit procedures, and adopting internationally recognized transparency measures. Those reforms enhanced the credibility of the authority’s financial management internationally, restarted the flow of external aid and PA revenues withheld by Israel, and helped temporarily end a financial crisis.

Tristan Dreisbach drafted this case study based on interviews conducted in the Palestinian cities of Ramallah, Nablus, and Jericho in June and July 2019 and on a series of conversations with Salam Fayyad in Princeton, New Jersey, the same year. The case is part of a series on state building in Palestine, 2002–05 and 2007–11. Case published March 2022.

When Salam Fayyad became the Palestinian Authority’s finance minister in June 2002, one of his biggest challenges was to improve financial management in the security sector. To pay police, emergency workers, and other security personnel, commanders handed out cash to subordinates—a practice that was demeaning and that created opportunities for corruption. Procurement of equipment and supplies was neither open nor competitive and took place outside scrutiny by the finance ministry, which had little or no way of knowing where the government’s money ended up. To address the problems, Fayyad, a political outsider, had to take on a deep-rooted culture of secrecy, the reluctance of a powerful president, and resistance from some of the security officials. He began to tighten controls by working with a reform-minded legislature to incorporate procedural changes into the 2003 budget law. He then identified security service chiefs who were open to payroll reform, and he helped them become early adopters. After more than a year of private persuasion, backed by growing public discontent with corruption, Fayyad was able to implement reforms that reduced opportunities to divert funds and that increased security workers’ take-home pay. He also put security forces’ procurement activities under finance ministry oversight, thereby further limiting the risk of corruption.

Tristan Dreisbach drafted this case study based on interviews conducted in the cities of Ramallah, Nablus, and Jericho in June and July 2019 and on a series of conversations with Salam Fayyad in Princeton, New Jersey, the same year. The case is part of a series on state building in Palestine, 2002–05 and 2007–11. Case published March 2022.

During the first decade and a half after Nigeria returned to democracy in 1999, the country struggled to adequately fund its primary health care system. Despite a nearly 10-fold increase in the size of the economy, Nigeria in 2014 was still spending only US$11 per capita on health care—equal to only 6% of total government expenditure and far below regional norms and the nation’s own stated aspiration. As a result, Nigerian citizens were paying 69% of their medical expenses out of pocket, and the cost discouraged many from seeking treatment. A new National Health Act, adopted in 2014 after a decade of delay, raised hopes for a solution by stipulating that at least 1% of the government budget go into a new fund to improve basic services provided at the thousands of primary health care clinics located throughout the country. However, owing to Nigeria’s longstanding neglect of primary health care, there was a real risk that the fund might never become reality. To demonstrate the viability of the program and press for its implementation, the federal health ministry, led by Minister Isaac Adewole, developed operational procedures that spelled out crucial steps to ensure financial accountability and transparency, won international backing for a pilot project that would validate the system, and built a support coalition that spanned the government and civil society. The effort took three years, but in 2018 the Nigerian legislature passed an appropriations bill that for the first time included the 1% allocation for the fund—significantly boosting the resources available to improve the quality and accessibility of primary health care services across Nigeria. Even more significantly, in September 2019, the government declared the fund a statutory allocation that it would automatically renew every year, and clinics in three states began receiving the new resources in November 2019.

Leon Schreiber drafted this case study based on interviews conducted in Abuja, Nigeria, in July and August 2019 with the help of Bunmi Otegbade. Case published November 2019.

In 2005, Vietnam’s legislature voted to develop a new health insurance system that would reduce most citizens’ out-of-pocket health-care costs and instructed the health ministry to take steps to make care more accessible, more affordable, and more effective—especially for those who lived in remote, mountainous regions. One of the challenges was how to manage scarce resources in order to constrain soaring costs. Another was how to coordinate with provinces and local governments (districts and communes)—which controlled much of the country’s health-care spending—in order to achieve national priorities, such as improved preventive care. During the next several years, the health ministry’s Department of Planning and Finance worked with those subnational units to improve the financial information system, hone strategies and plans, and align activities. By 2014, Vietnam’s government had more than tripled its per-capita health-care spending—to US$48.82 in 2014 from US$15.52 per capita in 2005, in current US dollars—a rate of growth that outpaced the average in both low-income and lower-middle-income countries. Although the ministry still struggled to keep patients’ costs down, the share of out-of-pocket spending fell to 45% in 2015 from 67% in 2005, according to government figures.

ISS staff members drafted this case study based on interviews conducted in Hanoi, Vietnam by Simon Engler and Huong Dang in May, June, and August 2018. Case published in May 2019. This case is part of an ISS series on linking health priorities to the budget process.

Ethiopia’s Federal Ministry of Health was struggling to meet its goals in 2014 despite impressive gains in the health of its citizens during the previous 20 years. A new minister and his leadership team reached out for ideas by engaging Ethiopia’s regions, districts, and communities—an essential step in a large and ethnically diverse society. They then developed an ambitious transformation program to help realize the government’s national aspirations for health care, including commitments made to achieving the Millennium Development Goals. To bring their vision to fruition, however, the minister and his team had to link priorities to the budget process and use the health budget as a management tool. The ministries of health and finance matched goals and targets to available resources and worked to create actionable plans. And health officials took steps to build cooperation and extend coordination at every level of government in Ethiopia’s federal system. Technical and capacity constraints—plus unexpected political upheaval beginning in late 2015—slowed implementation, but in 2018 a new administration was taking steps to address those challenges.

Gordon LaForge drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published January 2019.

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In 2009, South Africa's health-funding system teetered on the verge of collapse. Despite the adoption of a transparent and credible budget framework in 1994, large parts of the public health system suffered from chronic overspending and poor financial control. As wage hikes and supply costs ate into the health budget and as government revenues plummeted in the wake of the 2008 global financial crisis, the national health department had to find ways to preserve priorities, linking them more effectively to the budget. The department won agreement on a list of non-negotiable expenditure items to protect in provincial budgets, used earmarked conditional grants to channel funds to key programs, cut medicine costs by improving central procurement, rolled out a new information technology system, and improved its monitoring of provincial finances. Although the country's nine provincial health departments had important roles to play, most of them struggled. However, the Western Cape was able to set a model by controlling personnel costs, improving monitoring, and creating incentives for health facilities to collect fees. Nationally, total per-capita government revenues dropped by 5% in the immediate aftermath of the financial crisis and grew only slowly thereafter, but the health sector's strategy helped ensure progress on its key priorities even as resources fluctuated.

Leon Schreiber drafted this case study based on interviews conducted in Pretoria and Cape Town, South Africa, in August 2018. Case published October 2018.

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Rwanda’s public health system was among the many casualties of the country’s 1994 genocide. In the aftermath of the violence, health workers were in short supply, maternal and child mortality rates spiked, and infectious diseases such as HIV/AIDs and tuberculosis often went untreated. By 2011, Rwanda had made enormous progress in remedying the situation, but much more remained to be done. From 2011 to 2016, officials in the finance ministry and health ministry worked together to develop five-year plans for public health, translate their new priorities into annual budgets, and monitor spending so as to ensure progress toward national goals. They revised the budget calendar to improve the planning process, helped local authorities build medium-term public-health strategies, and refined the tools used for tracking spending in the health sector. They met or surpassed more than half of the top targets they set for 2015, cementing the gains Rwanda had made since 1994.

Simon Engler drafted this case study with the assistance of Louise Umutoni Bower, based on interviews conducted in Kigali, Rwanda in March, April and August 2018. Case published September 2018.

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